Higher Acuity Outpatient Spine Surgery

Lianne McDowell

Robert Tatsumi, MD

Acuity Definition

• Simple: – lumbar decompression, kyphoplasty, cervical

foraminotomy

• Middle: – laminoplasty, ACDF

• Complex: – ADR, ALIF, PSF, LLIF – Keep for 23 hours

Dr. Bray. Lessons on performing high acuity cases in ASC. Orthopedic, Spine & Pain Management Driven ASC’s. 10

Outpatient Criteria

• Criteria

– Live 30 minutes from a hospital

– BMI<42

– Cardiology evaluation

– Caregiver for 24 hours after surgery

– ASA: Low to moderate

Chin KR, Coombs AV, Seale JA. Feasibility and patient reported outcomes after outpatient single-level instrumented lumbar interbody fusion in a surgery center. Spine. 40;1. E36-42. 2014

30 Day Readmissions for ACDF

• NSQIP Database from 2012-2014– 17,088 patients with elective ACDF

• 545 (3.2%) Readmissions– 293 (53.8%) Nonsurgical site related reasons

» Neuropsychiatric 44

» Cardiovascular 39

» Pneumonia 37

– 184 (33.8%) Surgical site related

» Infection 42

» Hematoma 42

» Dysphagia 32

– 84 Undocumented

Samuel, AM, et al. Most 30 day Readmissions After Anterior Cervical Discectomy and Fusion Are Not Due to Surgical Site-Related issues: An analysis of 17,088 Patients. Spine 41(23):1801-1807, 2016.

Spine Cases (2011 -2016)

• Total cases 1136

– 2011 - 78

– 2012 - 169

– 2013 - 187

– 2014 - 221

– 2015 - 259

– 2016 - 227 0%

50%

100%

150%

200%

250%

2011 2012 2013 2014 2015 2016

% Increase

Cases Types

Case Type Number Male Female Average SurgicalTime (min)

AverageRecovery Time (hour & min)

Lumbar decompression 648 396 252 56 1:47

Lumbar decompression >2 levels

93 52 41 68 1:54

ACDF 179 92 87 54 2:03

ACDF >2 levels 81 36 45 87 3:13

ADR 86 43 43 73 2:27

0

20

40

60

80

100

120

140

160

2011 2012 2013 2014 2015 2016

Single Level Decompression

0

5

10

15

20

25

30

35

40

45

50

2011 2012 2013 2014 2015 2016

Single Level ACDF

0

2

4

6

8

10

12

14

16

18

20

2011 2012 2013 2014 2015 2016

Artificial Disc Replacement

Higher Acuity Cases

Case Type Number Male Female Average SurgicalTime (min)

Average Recovery Time (hour & min)

ACDF >2 levels 81 36 45 87 3:13

Spinal Cord Stimulator 38 21 17 66 2:01

Lumbar fusion 5 4 1 106 2:16

0

5

10

15

20

25

2011 2012 2013 2014 2015 2016

Two Level ACDF

0

5

10

15

20

25

2011 2012 2013 2014 2015 2016

Stimulator Implants

Complications

Issue Number Male Female Average SurgicalTime

Dural tear 5 3 2 60

Death 0

Stroke 0

Myocardial infarction 0

Transfusion 0

Transfers

• Spinal cord stimulator (3)

– Pain control x2

– Neurologic changes x1

• ACDF (1)

– Anesthesia reaction

4 C’s To Think About

• Care

• Competency

• Cost

• Complications

Care

• Always keep your patient safe.

• Resist the temptation to stretch your indications for financial gain.

Competency

• How do you know if you can safely perform an outpatient case safely?

• Look at YOUR own results.

– Review YOUR outpatient data!

– Review YOUR complications!

– Review YOUR operative times!

Cost

• Understand the surgery center reimbursement for your cases– Facility reimbursement for the procedure

• Control your costs– Staffing time

• Efficiency in staff scheduling/fast track options

– Implant costs• Disposable associated costs • Shipping

– Supply costs • Case cost by surgeon • Materials management

– Biologic costs– Special equipment

• Cell saver• Neuromonitoring

Cost

• Examples of a profitable vs non profitable case.

• Artificial disc replacement (higher cost) –

– Poor contract 50% loss on case

• Double level ACDF (higher cost) -

– Good contract 77% net profit on case

• Decompression (lower cost) –

– Good contract 82% net profit on case

Cost Continued - Trending

Costs per Case: Implants and Supplies 2011 to Current

% Decrease

ACDF -44%

Artificial Disc -21%

Decompressions -28%

Spine Profit and Loss to the Center

Spine Payer Mix

Spine Payer Mix

OONIn-

network Medicare MVAWork Comp Self Pay

2011 62% 24% 0% 7% 4% 3%

2012 58% 21% 3% 11% 1% 5%

2013 21% 61% 1% 8% 3% 3%

2014 28% 61% 1% 2% 7% 1%

2015 18% 68% 6% 4% 2% 1%

2016 13% 72% 9% 2% 3% 2%

Spine Annual Net Income

0%

5%

10%

15%

20%

25%

30%

35%

40%

2011 2012 2013 2014 2015 2016

% Center Net Annual Income

Complications

• Be prepared!

• Have a plan in place

• Vascular injury

– ALIF/TLIF/LLIF

• Bowel injury

– LLIF

• Cord injury

– SCS, VCF

Conclusion

• Higher acuity spine surgery can be performed safely.

• Remember the 4C’s

– Care

– Competency

– Cost

– Complications

Thank You